Provider Demographics
NPI:1568610574
Name:ADVANCED EYECARE OF BLACKFOOT PLLC
Entity Type:Organization
Organization Name:ADVANCED EYECARE OF BLACKFOOT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-528-6900
Mailing Address - Street 1:1213 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1654
Mailing Address - Country:US
Mailing Address - Phone:208-782-3426
Mailing Address - Fax:208-782-3436
Practice Address - Street 1:1213 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1654
Practice Address - Country:US
Practice Address - Phone:208-782-3426
Practice Address - Fax:208-782-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370132Medicare UPIN